Currentsanford health planPolicy PR-020

Institutional Provider Credentialing

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Governs credentialing and recredentialing procedures for organizational (institutional) providers contracting with Sanford Health Plan, affecting hospitals, clinics, home health agencies, skilled nursing facilities, behavioral health facilities, and other listed organizational provider types.

Policy Summary

Payersanford health plan

PolicyInstitutional Provider Credentialing

Policy CodePolicy PR-020

Change TypeNo material changes

Effective Date

Last ReviewDec 27, 2021

Next Review Date

Key ActionOrganizational providers must complete and return a Facility/Agency Credentialing Application with supporting documentation to contract with the Plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180 daysCommittee decision timeframe after documents collected

3 yearsOn-site visit / recredentialing frequency

$1M/$3MMinimum professional liability

NCQA QI 2 CR 7Referenced standard

Credentialing Requirements and Criteria

Credentialing criteria

Criteria and processes required for credentialing organizational providers:

Completed Facility/Agency Credentialing Application and all supporting documentation must be submitted to the Plan.

Plan shall verify current state and federal licensing and regulatory requirements and good standing by receiving a current copy of the facility license or directly from the applicable state or federal agency.

Plan shall identify accreditation status and receive a copy of current accreditation or verify directly with the accrediting body; hospitals are not required to be accredited by The Joint Commission.

If not accredited

Plan shall substitute a CMS or state review in lieu of the required site visit and review the CMS/State survey.
Organizational provider must correct any deficiencies identified by CMS or State reviewers prior to Committee approval; Plan may accept a CMS/State approval letter stating the provider passed inspection.

If no completed CMS or State review exists, the Plan will perform an on-site quality assessment; on-site visits are conducted every three years for non-CMS/State reviewed organizational providers (exceptions apply for certain rural providers).

Organizational provider must furnish a current Certificate of Insurance or Medical Insurance Face Sheet verifying professional liability coverage at a minimum of $1,000,000 occurrence / $3,000,000 aggregate or $2,000,000 occurrence / $2,000,000 aggregate.

Plan will query EPStaff Check for OIG/Mediregs and SAM sanctions to verify no sanctions exist for the organizational provider.

Sanford Health Plan may request additional quality and safety information via the Facility Application Disclosure Questions; the Credentials Committee will review affirmative responses and may request explanations or supporting documents.

When all required information has been verified and reviews/site visits completed (if necessary), the Credentialing Committee will review the application and may approve, deny, or return the application for clarification; the Committee decision will be made within 180 days of collected documents. The Senior Director Medical Services may approve complete files without identified concerns.

Recredentialing: at least every three years the Plan shall confirm continued good standing with regulatory bodies and accrediting organizations; an on-site visit will be conducted if the organizational provider has not been reviewed by an accrediting body or CMS/state governing body within the past three years.

Sanford Health Plan adopts CMS and/or state standards and regulations for parameters required for contracting for each specific type of organizational provider.

Application Submission Requirements

Prior Authorization

Submit Facility/Agency Credentialing Application

Organizational providers seeking to contract with the Plan must complete and return a Facility/Agency Credentialing Application along with all supporting documentation to the Plan.

Submit a fully completed Facility/Agency Credentialing Application.
Include all required supporting documentation with the application.

Key Definitions: Organizational Provider

Organizational provider — included types

HospitalsIncluded as organizational providers eligible for credentialing.

Home health agenciesIncluded as organizational providers eligible for credentialing.

Skilled nursing facilitiesIncluded as organizational providers eligible for credentialing.

Free-standing surgical centers / Ambulatory surgery centersIncluded; listed explicitly and as an additional institution eligible for credentialing.

Behavioral health facilitiesIncludes facilities providing mental health or substance abuse services in inpatient, residential, and ambulatory settings (e.g., psychiatric hospitals, clinics, addiction disorder facilities, residential treatment centers).

Other institutional typesAlso includes hospice, home infusion therapy, ambulance, end stage renal disease centers, durable medical equipment suppliers, independent labs, radiology/imaging centers, comprehensive outpatient rehab, outpatient PT and speech pathology, diabetes self-management centers, portable x-ray suppliers, rural health clinics, and federally qualified health centers.

Policy Summary

Payersanford health plan

PolicyInstitutional Provider Credentialing

Policy CodePolicy PR-020

Change TypeNo material changes

Effective Date

Last ReviewDec 27, 2021

Next Review Date

Key ActionOrganizational providers must complete and return a Facility/Agency Credentialing Application with supporting documentation to contract with the Plan.

SourceLink

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Institutional Provider Credentialing

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Credentialing Requirements and Criteria

Credentialing criteria

Criteria and processes required for credentialing organizational providers:

Completed Facility/Agency Credentialing Application and all supporting documentation must be submitted to the Plan.

Plan shall identify accreditation status and receive a copy of current accreditation or verify directly with the accrediting body; hospitals are not required to be accredited by The Joint Commission.

If not accredited

Plan shall substitute a CMS or state review in lieu of the required site visit and review the CMS/State survey.
Organizational provider must correct any deficiencies identified by CMS or State reviewers prior to Committee approval; Plan may accept a CMS/State approval letter stating the provider passed inspection.

Plan will query EPStaff Check for OIG/Mediregs and SAM sanctions to verify no sanctions exist for the organizational provider.

Sanford Health Plan adopts CMS and/or state standards and regulations for parameters required for contracting for each specific type of organizational provider.

Application Submission Requirements

Prior Authorization

Submit Facility/Agency Credentialing Application

Organizational providers seeking to contract with the Plan must complete and return a Facility/Agency Credentialing Application along with all supporting documentation to the Plan.

Submit a fully completed Facility/Agency Credentialing Application.
Include all required supporting documentation with the application.

Key Definitions: Organizational Provider

Organizational provider — included types

HospitalsIncluded as organizational providers eligible for credentialing.

Home health agenciesIncluded as organizational providers eligible for credentialing.

Skilled nursing facilitiesIncluded as organizational providers eligible for credentialing.

Free-standing surgical centers / Ambulatory surgery centersIncluded; listed explicitly and as an additional institution eligible for credentialing.